Pericardiocentesis

 

Pericardiocentesis is the removal of fluid from the pericardial cavity which can be approached in 2 ways

A sternal approach

A needle is inserted at the intercostal space 5 or 6 on the left side near the sternum the cardiac notch of the left lung least a fibrous pericardium exposed at the site the needle penetrates the following structures skin superficial fascia pectoralis muscle external intercostal membrane internal intercostal muscle transverse thoracic muscle fibers pericardium parietal layer of serous pericardium

The internal thoracic coronary arteries and pleura may be damaged during this approach

Subxiphoid approach

Needle was inserted at the left infrasternal angle angled in a superior posterior position

The needle penetrates the skin super fascia anterior rectus muscle rectus abdominis transverse abdominis fibrous pericardium parietal layer of serous pericardium

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for the sub xiphoid convergent approach

you want to identify the xiphoid process

you want to create a pericardial window

so that you can actually create access

to that posterior left atrium and have a

nice shallow angle some physicians will

remove this iphone process to make that

access easier you want to make sure that

the pericardial window is created just

above the bifurcation between the

pericardium and the diaphragm giving you

a nice shallow angle to that posterior

left atrium that allows you to insert

the cannula and be able to create that

space so you can visualize the different

structures such as the ivc

the right inferior pulmonary vein

the right superior palm vein

the left inferior pointer vein the

superior part of veins a lot of times

will not be directly visible but

sometimes if you can get up as high as

possible you can see that you want to

appreciate the ablation device before

you insert it through the cannula so

that you can actually access it and

advance it deflect it off the

pericardium up as high as possible to

approach those posterior pericardial

reflections along the roof to the left

atrium you're going to create a series

of lesions with the ablation device

distally and proximally so you're

blading as much of the posterior left

atrium as possible won't have just a

single row you'll typically have two

rows or even more to make sure you're

ablating as much of the posterior left

atrium as a physician wants to you're

going to go in and create the posterior

ablation from the right point veins to

the left palm veins making sure that

you're happy with the lesions

you can directly visualize the lesions

to make sure that they intersect but

afterwards what you typically will

utilize is the sensing function of the

epison's device to make sure that you

don't have any signals if you do have

any signals you're going to want to go

out there and repeat the ablation to

make sure you've fully isolated and

silence that entire posterior left

atrium

after you create all your incisions

you're going to remove the device remove

the cannula and you're going to

basically go in and close your incisions

you